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March 22, 2023 Terence Komtangi, Authorized Agent D Square Healthcare Services Inc. 2011 Saint Francis Avenue Shakopee, Minnesota 55379 License Number: 1109713 (245D – HCBS) CORRECTION ORDER Dear Terence Komtangi: On March 8, 2023, a licensing review of D Square Healthcare Services Inc., located at 2011 Saint Francis Avenue, Shakopee, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For two of three persons whose records were reviewed (P1 and P3), the license holder did not provide orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. a. P1’s services were initiated on December 22, 2021. The license holder failed to provide P1 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder failed to provide this orientation until March 2, 2023. b. P3’s services were initiated on January 27, 2023. The license holder failed to provide P3 and P3’s legal representative with orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. Corrective Action Ordered: Immediately, upon receipt of this order, you must provide P3 and P3’s legal representative with orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults. You must maintain documentation of this orientation to maltreatment reporting policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. The license holder failed to include an individualized assessment of P1’s susceptibility to abuse by others, P1’s risk of abusing other adults, and provide statements of the specific measures to be taken to minimize the risk of abuse to P1 and other vulnerable adults.P1’s IAPP documented that P1 was not susceptible to abuse or at risk of abusing other vulnerable adults, however, this assessment was not consistent with information reviewed elsewhere in P1’s record. The coordinated services and supports plan (CSSP) completed by P1’s case manager indicated that P1 was susceptible to self-abuse. b. The license holder failed to review P1’s IAPP annually, using the individual assessments and any reports of abuse related to P1. The plan shall be revised to reflect the results of this review. c. The license holder failed to include an individualized assessment of P2’s susceptibility to abuse by others, P2’s risk of abusing other adults, and provide statements of the specific measures to be taken to minimize the risk of abuse to P2 and other vulnerable adults.P2’s IAPP documented that P2 was not susceptible to abuse or at risk of abusing other vulnerable adults, however, this assessment was not consistent with information reviewed elsewhere in P2’s record. The coordinated services and supports plan (CSSP) completed by P2’s case manager indicated that P2 was susceptible to self abuse. d. The license holder failed to develop an IAPP as part of P3’s initial individual program plan or service plan prior to or upon service initiation. P3’s services were initiated on January 27, 2023 and at the time of the review, the license holder had not developed an IAPP. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop an IAPP for P3 to include individualized assessments of susceptibility to abuse and provide statements of the specific measures that would be taken to minimize the risk of abuse for each assessed area; and · review P3’s IAPP with P3, P3’s legal representative, and other members of P3’s support team. Within 60 days of receiving this order, you must: · revise the IAPP’s for P1 and P2 to include individualized assessments of susceptibility to abuse and provide statements of the specific measures that would be taken to minimize the risk of abuse for each assessed area; · review P1 and P2’s IAPP with P1 and P2, P1 and P2’s case managers, and other members of P1 and P2’s support team; and · submit copies of P1-P3’s IAPP’s to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide a written notice that identified the service recipient rights as required.. The license holder failed to provide P1 with a written notice that identified the service recipient rights in subdivision 2 and 3, and an explanation of those rights within 5 working days of service initiation and annually thereafter. The license holder did provide P1 with notice and explanation of the service recipient rights on March 2, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose record were reviewed (P1 through P3), the license holder did not provide written or electronic copies of policies and procedures as required. a. The license holder failed to inform the P1 and P1’s case manager of the policies and procedures affecting P1’s rights under section 245D.04, and provide copies of the following policies and procedures, within 5 working days of service initiation: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. b. P2’s services were initiated on December 30, 2022. Although the license holder did inform P2 of the policies and procedures affecting P2’s rights under section 245D.04, and provided copies of the following policies and procedures on December 30, 2022, the license holder failed to inform and provide copies of the following policies and procedure to P2’s case manager within 5 working days of service initiation: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. c. The license holder failed to inform the P3, P3’s legal representative and P3’s case manager of the policies and procedures affecting P3’s rights under section 245D.04, and provide copies of the following policies and procedures, within 5 working days of service initiation: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. Corrective Action Ordered: Within 30 days of receiving this, you must: · inform and provide copies of the above mentioned policies and procedures to P2’s case manager; and · inform and provide copies of the above mentioned policies and procedures to P3, P3’s legal representative and P3’s case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three persons whose record were reviewed (P1 through P3), the license holder did not meet the requirements for assessment and initial service planning as required for intensive support services. a. The license holder failed to complete assessments of P1’s overall strengths, functional skills and abilities, and behaviors and symptoms in the following areas within 45 days of service initiation and annually thereafter: · P1's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · P1's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · P1's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. b. The license holder failed to meet with P1, P1’s case manager, and other members of the support team or expanded support team within 45 days of service initiation to complete assessments in the following areas. The license holder did complete the assessments on May 5, 2022. · the scope of the services to be provided to support P1's daily needs and activities; · P1's desired outcomes and the supports necessary to accomplish the person's desired outcomes; · P1's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; · whether the current service setting is the most integrated setting available and appropriate for the P1; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for P1; and · a discussion of how technology might be used to meet P1's desired outcomes. The coordinated service and support plan or support plan addendum must include a summary of this discussion. The summary must include: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. c. The license holder failed to complete assessments of P2’s overall strengths, functional skills and abilities, and behaviors and symptoms in the following areas within 45 days of service initiation: · P2's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · P2's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · P2's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. d. The license holder failed to have a discussion with P2, P2’s case manager and other members of the support team of how technology might be used to meet P2's desired outcomes. The coordinated service and support plan or support plan addendum must include a summary of this discussion. The summary must include: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. e. The license holder failed to complete a preliminary support plan for P3 within 15 days of service initiation. P3’s services were initiated on January 27, 0223 and at the time of the licensing review, the license holder did not have a support plan for P3 created. Corrective Action Ordered: Within 60 days of receiving this order, you must: · complete the required assessments for P1 and P2 that produce information about the person that describes the person’s overall strengths, functional skills, and abilities; · review the results of the assessments of P1 and P2’s ability to self- manage health and medical needs, personal safety, and symptoms or behaviors with P1 and P2, P1 and P2’s case manager and members of the support team. You must document this review; · have a discussion with P1 and P2, P1 and P2’s case manager and other members of the support team about how technology might be used to meet P1 and P2’s desired outcomes and include a summary of this discussion in P1 and P2’s support plan; · complete a preliminary support plan for P3; and · submit copies of the required assessments for P1 and P2 to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop a service plan that documents the service outcomes and supports as required. The license holder failed to develop a service plan that documented the service outcomes and supports based on the assessments and person-centered planning for P1 and P2. The license holder did complete the assessments for P1 and P2’s desired outcomes, however, the outcomes failed to document the following: · Methods of actions that will be used to support the person and to accomplish the service outcomes; · The measurable and observable criteria for identifying when the desired outcomes had been achieved; · The projected starting date for implementing the supports and methods; and · The names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop a service plan for P1 and P2 that documents the service outcomes and supports that includes the following: o the methods or actions that will be used to support P3 and to accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person’s communication mode and learning style; o the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; o the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and o the names of the staff or position responsible for implementing the supports and methods. · submit a copy of the service outcomes for P1 and P2 to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for service plan review and evaluation. The license holder failed to meet with P1, P1’s case manager and other members of the support team to participate in the ongoing review and development of the service plan and methods used to support the person and accomplish outcomes. The annual review must include the following: · a discussion about how technology might be used to meet the person's desired outcomes; o The support plan addendum must include a summary of this discussion. The summary must include a statement regarding any decision made related to the use of technology and a description of any further research that must be completed before a decision regarding the use of technology can be made; and · a summary of the person's status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4 in a report available at the time of the progress review meeting; Corrective Action Ordered: Within 60 days of receiving this order, you must meet with P1, P1’s case manager and other members of the support team to participate in the ongoing review and development of P1’s support plan. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For two persons whose record were reviewed (P1 and P2), the license holder did not incorporate and evaluate positive support strategies as required. The license holder failed to incorporate positive support strategies in writing into P1 and P2’s existing support plan. Additionally, the license holder failed to evaluate the identified positive support strategies with P1 every 6 months. Corrective Action Ordered: Within 60 days of receiving this order, you must incorporate positive support strategies in writing into P1 and P2’s existing support plan. Additionally, you must evaluate the identified positive support strategies with P1 and P2 every 6 months. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 72 hours as required. The license holder failed to ensure SP1 and SP2 received an orientation to the reporting requirements and definitions in sections 626.557 and 626.5572, the requirements of this section, and the license holder's internal policies and procedures related to the prevention and reporting of maltreatment of individuals receiving services, within 72 hours of first providing direct contact services as defined in section 245C.02. SP1 was hired on January 30, 2023. While the date that SP1 first provided direct contact services to a vulnerable adult was not documented in SP1’s personnel record, the license holder reported that SP1 has provided direct contact services since they were hired.. SP2 was hired and first provided direct contact services to a vulnerable adult served by the program on January 2, 2023. At the time of the licensing review on March 8, 2023, the license holder had not provided this orientation to SP1 or SP2. Corrective Action Ordered: Immediately upon receipt of this order, you must provide SP1 and SP2 with an orientation to the requirements identified above. Additionally, you must maintain documentation of this orientation in SP1 and SP2’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. a. SP1 was hired on January 30, 2023. While the date that SP1 first provided unsupervised direct contact services to a person served by the program was not documented in SP1’s personnel record, the license holder reported during the licensing review, that SP1 has provided unsupervised direct contact services to persons served by the program since their hire date. The license holder failed to ensure SP1 reviewed and received instruction on the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, and the person’s individual abuse prevention plan, before having unsupervised direct contact with a person served by the program. b. SP2 was hired on January 2, 2023. The license holder failed to provide SP2 with an orientation to the following within 60 days of hire: · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under Minnesota Statutes, section 245D.06, subdivision 1; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · the license holder’s current policies and procures required under Minnesota Statutes, chapter 245D, including their location, access, and staff responsibilities related to the implementation of those policies and procedures; · data privacy requirements according to Minnesota Statutes, section 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · the principles of person-centered planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. c. SP2 first had unsupervised contact with a person served by the program on January 2, 2023. The license holder failed to ensure SP2 reviewed and received instruction on the person’s support plan or support plan addendum as it related to the responsibilities assigned to the license holder, and the person’s individual abuse prevention plan, before having unsupervised direct contact with a person served by the program. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with training on the topics identified above. Additionally, you must maintain documentation of this training in SP1 and SP2’s personnel record as required in Minnesota Statutes, section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP3), the license holder did not provide annual training as required. 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder failed to provide SP3 with annual training on the following topics in 2022: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · sections 245A.65, 245A.66, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP3 with training on the topics identified above. Additionally, you must maintain documentation of this training in SP3’s personnel record as required in Minnesota Statutes, section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not maintain personnel records as required. a. The license holder failed to maintain a personnel record for SP1 that included documentation of the following in SP1’s personnel record: · the date of SP1’s first supervised contact with a person served by the program; · the date of SP1’s first unsupervised contact with a person served by the program; · SP1’s orientation and training, that included: o the date the training was completed; o the number of hours per subject area; and o the name of the trainer or instructor. b. The license holder failed to maintain a personnel record for SP2 that included documentation of SP2’s orientation and training, that included: o the date the training was completed; o the number of hours per subject area; and o the name of the trainer or instructor. c. The license holder failed to maintain a personnel record for SP3 that included documentation of SP3’s orientation and training, that included: o the date the training was completed; o the number of hours per subject area; and o the name of the trainer or instructor. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245C.04, subdivision 1, and section 245A.07, subdivision 3, paragraph (d). Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not meet requirements for submitting background studies as required. a. SP2 began a position allowing direct contact services with a person served by the program on January 2, 2023. The license holder failed to initiate a background study on SP2 before they began a position allowing direct contact with persons served by the program. The license holder initiated a background study on SP2 on January 3, 2023. Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d), the Commissioner shall not issue a fine to a license holder who self-corrects a background study violation before the Commissioner discovers the violation. A license holder who has previously exercised the provision of paragraph (d) to avoid a fine for a background study violation may not avoid a fine for a subsequent background study violation unless at least 365 days have passed since the license holder self-corrected the earlier background study violation. Because the license holder self-corrected the background study violation involving SP2 before the Commissioner discovered the violation, the license holder is not being fined for the background study violation involving SP2. Corrective Action Ordered: On an ongoing basis, you must maintain compliance with background study requirements in Minnesota Statutes, chapter 245C. 14. Citation: Minnesota Statutes, section 245D.081. Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight. a. The license holder failed to ensure that the designated coordinator (SP3), provided supervision, support, and evaluation of activities that include: · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; and · evaluation of the effectiveness of services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. b. The license holder failed to ensure that the designated manager (SP3) provided program management and oversight of the services provided by the license holder that include: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivision 4, 4a, and 5. See citations 1 through 13 for the designated coordinator and designated manager’s failure to provide the above stated requirements. Corrective Action Ordered: Within 60 days of receiving this order, you must follow the corrective action ordered throughout this order and submit evidence of completion as requested. On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at Amber.N.Nielsen@state.mn.us; or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Amber Nielsen Licensing Division PO Box 64242 St. Paul, MN 55164-0242 B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Christala Culhane, HCBS Unit Supervisor Licensing Division Office of Inspector General 651-431-6541
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